Family Health Exam 1 Flashcards
Acrocyanosis
Acrocyanosis” refers to cyanosis found in the extremities, particularly the palms of the hands and the soles of the feet. It can also be seen on the skin around the lips. Acrocyanosis is often normal in babies, as long as no cyanosis is present in the central part of the body.
Active Acquired Immunity
Active immunity is created by our own immune system when we are exposed to a potential disease-causing agent (i.e., pathogen).
Apgar Score
Score of 7-10 = within desired limits
Score of 4-6 = oxygen, suctioning, stimulate the baby, rub the baby’s back.
Score of 0-3 = full code / resuscitation
A = Activity (Muscle Tone) 0 = absent; 1 = flexed arms and legs; 2 = active
P= Pulse 0 = absent, 1 is <100bpm; 2 is >100 bpm
G = Grimace (reflex irritability) 0 = floppy; 1 = minimal response to stimulation; 2 = prompt response to stimulation
A = Appearance (skin color) 0 = blue or pale; 1 = pink body, blue extremities; 2 = pink
R = respiration 0 = absent; 1 = slow and irregular; 2 = vigorous cry
Barlow Maneuver
Baby is on its back
Palm is in the palm of the examiner
Thumb is on the medial aspect
fingers on the lateral aspect
Do the test one side at a time
Bring the leg inward (adduction) and push backwards (towards the bed).
This tests if the hip is sublaxable (can be easily dislocated of the acetabulum)
Ortolani Maneuver
Baby is on its back
Palm is in the palm of the examiner
Thumb is on the medial aspect
fingers on the lateral aspect
Do the test one side at a time
Bring the leg outward (abduction) and pull anteriorly (to the front).
This tests if the hip is coming out of the socket
Brazelton Neonatal Assessment Scale
Also called the Neonatal Behavioral Assessment Scale (NBAS)
It is a neurobehavioral assessment scale designed to describe the newborn’s responses to his/her new extrauterine environment and to document the contribution of the newborn infant to the development of the emerging parent-child relationship.
It is used to examine the effects of prematurity, low birthweight, undernutrition, and a range of pre-and perinatal risk factors, the effects of prenatal substance exposure, environmental toxins, temperament, neonatal behavior in different cultures, prediction studies, and studies of primate behavior.
Caput succedaneum
Caput succedaneum is swelling of the scalp in a newborn across the midline. It is most often brought on by pressure from the uterus or vaginal wall during a head-first (vertex) delivery. Swelling and bruising usually occur on the top of the scalp where the head first enters the cervix during birth.
Cephalohematoma
Cephalohematoma is a minor condition that occurs during the birth process. Pressure on the fetal head ruptures small blood vessels when the head is compressed against the maternal pelvis during labor or pressure from forceps or a vacuum extractor used to assist the birth.
Chemical conjunctivitis
When eye drops are given to newborns to help prevent a bacterial infection, the newborn’s eye(s) may become irritated. This may be diagnosed as chemical conjunctivitis. Symptoms of chemical conjunctivitis usually include mildly red eye(s) and some swelling of the eyelids.
Congenital dermal melanocytosis (Mongolian Spots)
The term congenital dermal melanocytosis refers to one or more birthmarks. They are flat blue or blue/grey spots with an irregular shape that commonly appear at birth or soon after. Congenital dermal melanocytosis are most common at the base of the spine, on the buttocks, back and shoulders.
Dubowitz / Ballard tool
The Ballard Score is used to assess gestational age / maturity. A lower Ballard Score indicates lower gestational age and vice versa.
Ballard’s score is most accurate when performed within the first 12-20 hours of life.
Six neuromuscular markers are assessed: posture, square window (degree of wrist flexion), arm recoil, popliteal angle (degree of knee flexion), scarf sign (ability to extend the infant’s arm across the chest past midline), and heal to ear extension.
Seven physical characteristics are also evaluated: skin, lanugo, plantar creases, breast, eye and ear, and genitals.
A normal pregnancy can range from 38-42 weeks, so this is a normal Ballard score. The full Ballard range is -10 to 50.
SGA babies
SGA = Small Gestational Weight –> at risk for chromosomal abnormalities, malformations, congenital infections like rubella and cytomegalovirus.
Would have a low Ballard score.
nursing interventions are to assure the baby is appropriately fed, prevent hypoglycemia with glucose monitoring and possibly glucose interventions; maintain the baby’s temperature; monitor serum hematocrit (normal is 45-65%), assess for possible infections.
LGA
LGA = Large Gestations Age
LGA babies are at risk for birth injuries due to their disproportionate size and might also have genetic or congenital disorders, frequently are male, and are also at risk for congenital heart disease “happy chubby blue male infant”
Nursing interventions are focused on observing for potential complications (particularly if the mom is diabetic) and management of birth injuries like a clavicle fracture, facial nerve injury, erb-duchenne palsy, klumpke paralysis, phrenetic nerve palsy, and potential skull fracture.
Epstein Pearls
Epstein pearls are small, harmless cysts that form in a newborn’s mouth during the early weeks and months of development. They contain keratin and usually go away within a few weeks. The bumps contain keratin, a protein that occurs naturally in human skin, hair, and nails.
Erb-Duchenne paralysis (Erb palsy)
Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth. The injury can either stretch, rupture or avulse the roots of the plexus from the spinal cord.
Erythema toxicum neonatorum
Erythema toxicum neonatorum (ETN) is a skin condition in newborns. Usually, ETN looks similar to acne. Red patches or small, fluid-filled bumps (pustules) may form on the baby’s face, limbs or chest. ETN isn’t dangerous and usually goes away on its own.
Finnegan Neonatal Abstinence Scoring Tool (FNAST)
reviews CNS disturbances, metabolic/vasomotor/respiratory disturbances, GI disturbances to create an overall score to assess infants exposed in utero to psychoactive drugs like opioids/opiates.
Score of 8+ indicates need for pharmacologic therapy.
All opioid exposed infants should have continuous monitoring via a cardiorespiratory monitor or pulse oximetry due to the potential for respiratory depression.
Infants should be scored every 3 hours throughout their hospital stay, but might need to be evaluated more frequently.
Habituation
If left in the same environment, over time they become accustomed to their surroundings and pay less attention to them. This process is called habituation. However, the moment something new happens, infants are ready to pay attention again.
harlequin sign newborn
Harlequin colour change appears transiently in approximately 10% of healthy newborns.1 This distinctive phenomenon presents as a well-demarcated colour change, with one half of the body displaying erythema and the other half pallor. Usually occurring between two and five days of age, harlequin colour change has been seen as late as three weeks of age.2 The condition is benign, and the change of colour fades away in 30 seconds to 20 minutes. It may recur when the infant is placed on her or his side.
Jaundice
Jaundice in newborn babies is common and usually harmless. It causes yellowing of the skin and the whites of the eyes.
Bilirubin
Bilirubin levels indicate jaundice.
Normal ranges:
<8.0 mg/dL for <24 hrs
<12 mg/dL for <48 hrs
<15 mg/dL for <5 days
Pathological jaundice
bilirubin is elevated within the first 24 hours of life. This often results from blood incompatibility, sepsis, infections like rubella, toxoplasmosis, occult hemorrhage, and erythroblastosis fetalis.
Pathological jaundice requires immediate nursing intervention - start with feeding (feed but also poop out the dead RBCs), warming, and then phototherapy.
Coombs
Tests mom & baby Rh factor
If the mom has a negative Rh factor and the baby has a positive Rh factor, the mother’s body will trigger antibodies against the baby’s positive antigen. These antigens will then mix into the baby’s body, which can be life threatening for the baby since their own body will be attacking their blood.
Give Rhogam if mom is Rh- and baby is Rh+
Newborn Glucose
Used to identify the glucose levels of the baby.
Normal range: 40 - 150 mg/dL
Hypoglycemia in newborns
<40 mg/dL
Results from mothers with diabetes, prematurity, or cold stress.
Nursing intervention is feeding and warming with ongoing glucose monitoring. If needed, provide the baby with 0% oral dextrose gel and possible IV infusion of D10W.
Warming is very important and helping the baby conserve energy.
Lanugo
Lanugo is soft, fine hair covering a fetus while inside the uterus. It helps protect them and keeps them warm while they grow. Some newborns have lanugo covering their bodies at birth, especially if they’re born prematurely. Lanugo can develop in people with eating disorders or certain tumors.
Meconium toxicology
The infant’s first stool can be used to test for fetal drug exposure during pregnancy. Meconium is used because it’s easier and more reliable than urine collection, and it’s easier to test at commercial labs.
Molding
During a head first birth, pressure on the head caused by the tight birth canal may ‘mold’ the head into an oblong rather than round shape.
Neonatal transition
The transition from fetus to neonate is a critical time of physiological adaptation. While the majority of term infants complete this process in a smooth and organized fashion, some infants experience a delay in transition or exhibit symptoms of underlying disease.
Neutral thermal environment (NTE)
The neutral thermal environment (NTE) has been defined as maintenance of the infants’ temperature with a stable metabolic state along with minimal oxygen and energy expenditure. The NTE is best achieved when infants can maintain a core temperature at rest between 36.5°C and 37.5°C.
Nevus Flammeus
A port wine stain (nevus flammeus) is a permanent birthmark that usually appears on the face.
nevus vasculosus (strawberry mark)
A strawberry nevus is a clump of tiny blood vessels that forms under the skin. It causes a raised red skin growth that may be present at birth or develop during infancy. A hemangioma looks like a strawberry birthmark, but it’s actually a benign (noncancerous) tumor. You may also hear the term vascular birthmark.
The tumor often grows for the first year and then shrinks, usually without treatment. About 10% disappear by the child’s first birthday. Of the rest, 90% of hemangiomas fade away by a child’s 10th birthday.
New Ballard SCore
the Ballard Score expanded to extremely premature infants.
Neonatal Infant Pain Scale
Used in children <1 year of age, as they cannot verbalize their pain. NIPS uses body language: facial expression, breathing pattern, state of arousal.
Score <3 indicates pain or discomfort.
Orientation
The infant turns its head towards sounds.
Passive-acquired immunity
Passive immunity is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system. A newborn baby acquires passive immunity from its mother through the placenta.
Periodic breathing
A baby may breathe fast several times, then have a brief rest for less than 10 seconds, then breathe again.
Physiologic anemia of infancy
Birth to three months – The most common cause of anemia in young infants is “physiologic anemia,” which occurs at approximately six to nine weeks of age. Erythropoiesis decreases dramatically after birth as a result of increased tissue oxygenation, which reduces erythropoietin production
Physiologic jaundice
A newborn’s immature liver often can’t remove bilirubin quickly enough, causing an excess of bilirubin. Jaundice due to these normal newborn conditions is called physiologic jaundice, and it typically appears on the second or third day of life.
Thrush
Thrush occurs when too much of a yeast called Candida albicans grows in a baby’s mouth.
Vernix caseosa
Vernix caseosa is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy. Vernix coating on the neonatal skin protects the newborn skin and facilitates extra-uterine adaptation of skin in the first postnatal week if not washed away after birth.
Expected finding.
Sudden infant death syndrome (SIDS)
Sudden infant death syndrome (SIDS) is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old. SIDS is sometimes known as crib death because the infants often die in their cribs.
Sudden unexpected infant death (SUID)
Sudden unexpected infant death (SUID) is a term used to describe the sudden and unexpected death of a baby less than 1 year old in which the cause was not obvious before investigation. These deaths often happen during sleep or in the baby’s sleep area.
Overlaying or accidental suffocation on a shared sleep surface. Accidental strangulation from unsafe surroundings. Wedging or entrapment. Immersion in water or drowning.
Expected Neonate Findings
Skin: pink or acrocyanosis, vernix, lanugo
Head: symmetrical, no bulging, but might see molding, caput (swelling crosses the suture line), cephalohematoma (blood b/w skull and periosteum that doesn’t cross the suture line)
Face: should be able to blink
Ears: should align with the outer canthus of eyes; not lower set (which indicates down syndrome)
Mouth: pink, moist, intact, epstein pearls
Neck/clavicle: no crepitus, no tenderness
Umbilical cord: Two Arteries & one vein (AVA)
Hips: expect equal leg length and symmetrical gluteal/thigh creases, no development dysplasia of the hip (Barlow and Ortolane manuevers)
Abnormal Neonate Findings
Skin: jaundice in the first 24 hrs; green or brown skin or under the nails
Ears: not lower set (which indicates down syndrome)
Neck/clavicle: injury
Hips: dysplasia of the hip (Barlow and Ortolane manuevers)
lbs to kg
1 kg = 2.2 lbs
Vitamin K
Intramuscular shot given within an hour of birth to prevent hemorrhage.
0.5mL – 1mL
Monitor for hemorrhage.
May monitor INR and PTT if necessary.
Monitor the skin for rashes.
While the baby will get some vitamin K from breast milk, it is usually low until they eat regular foods.
Vitamin K Deficiency Bleeds can be lethal and often have no warning signs.
Erythromycin
Eye ointment given within an hour of birth to prevent transmission of bacterial infections (specifically gonorrhea) from the mother to the newborn.
Hep B Vaccine
Whether the mother’s Hepatitis B surface antigen status is positive or negative, then the baby is given the hep B vaccine within 12 hours of birth
0.5mL IM within 12 hours of birth.
Series of 3 shots: within 12 hours of birth, at 1 month, and at 6 months.
Hep B Immunoglobulin (HBIG)
Given in addition to the Hep B Vaccine when the mom tests positive for Hep B.
Preferably given within the first 12 hours of birth.
The baby will be tested for the Hep B surface antigen and the antibody both at birth and at 9-12 months to confirm the course of treatment.
Oral Sucrose
Given to infants as analgesia for painful procedures.
24% Sucrose on the tongue results in slower heart beat and less crying during and after the procedure.
Babies 6 months and younger can have oral sucrose, and the RN can determine the need for this with your baby.
Mucus Secretion Suctioning
Expected.
It’s common to suction secretions from the mouth and the nose in order to clear the baby’s airway of mucus. This improves the baby’s ability to breathe.
Neonatal respiratory rate
Neonates generally have a range of 30-60 for a respiratory rate and have irregular breathing. It’s more important to look for other signs of struggling to breath, such as pulling in the ribs when taking a breath, grunting / wheezing / whistling sounds when breathing, flaring of the nares, bluish tone to the baby’s skin and lips, and if the breathing is both fast and shallow at the same time.
Neonatal Pulse Rate
The nurse’s assessment of the apical pulse would be within desired limits if the pulse is between 110-160 beats/min and somewhat irregular. However, a NICU intervention might be needed if the apical pulse is <110 or >160 beats/min with marked irregularities.
Phimosis
Concern.
It’s when the opening of the foreskin is too small to be pulled back over the glans. This is a concern because it might interfere with urinary, so the nurse would assess how well the baby can urinate.
Hypospadias
Hypospadias is when the urinary orifice is not positioned correctly; it is located on the ventral surface of the penis.
Infant Weight Range
The majority of infants weigh between 2500-4000g at birth. It is important to plot and document the weight so that the percentile weight of the baby can be established.
If the baby was <2500g, then he would be considered low birth weight (LBW).
Neonatal Breastfeeding
Newborn babies should feed every 2-3 hours or 8-14 times/day.
Hypotonia
Limp posture, extension of the extremities. This is a concern; the expected finding is active motion.
It might be caused by some form of brain damage, some disruption of nerves and muscles, infection, or lack of oxygen before the baby is born or immediately after.
If the baby is unable to swallow due to hypotonia, then the provider might decide to give the baby a feeding tube.
Pseudomenses
Pseudomenses is an expected or normal finding. It is a small amount of blood in the diaper because of the hormones that were ingested from the mother while in utero.
Depressed Anterior Fontanel
Concern.
A depressed anterior fontanel or sunken fontanel indicates that the baby doesn’t have enough food in her body, indicating dehydration.
The nurse would recommend increasing both the frequency and duration of breast feeding so that the baby can get more fluid and nutrients. If the mom can’t breastfeed enough for the baby, then supplementation with formula can be planned.
Tonic Neck Reflex Positive
Also called the Fencing Reflex; it’s normal.
High pitched cry
Concern - neuro injury of some kind.
When infants have an abnormally high-pitched cry, it is associated with something different with the infant’s metabolism and neurological development. The high pitch of the scream could be related to lower levels of activity in the baby’s vagal nerve. Massage therapies can stimulate vagal activities, improving the baby’s ingestion and helping them gain weight.
Dimple or Tuft of Hair on Spine
Concern.
A tuft of hair along the spine is one of the signs of spina bifida in babies. Spina bifida is a neural tube defect, when the posterior laminae of the vertebrae don’t close fully. This leaves an opening through which the spinal meninges and spinal cord might bulge through.
Causes of spina bifida include low folic acid intake, genetics, certain meds, women with diabetes, and obesity.
Clinical manifestations include paralysis, cognitive symptoms, abnormal brain development, and a birthmark/dimple/tuft of hair on the skin where the spinal defect is located.
Uneven gluteal folds
Concern - hip dysplasia
Uneven gluteal folds around a baby’s hips are a sign of developmental dysplasia of the hip – i.e. the hip pops out of the joint.
The nurse or provider might perform the Ortolani test, to confirm that the hip is dislocated. In this test, the clinician puts upward stress on the lateral thigh and with slow abduction, they will hear a clunk when the hip pops out of join.
The Barlow Maneuver is another test in which the clinician guides the baby’s hips into mild adduction and applies a slight forward pressure with the thumb. In an unstable hip, the femoral head will slip out.
Infants are usually treated with a soft brace that holds the hip joint in socket for several months.
Aldrete Score
The Aldrete score is a post-anesthesia discharge criteria that measures if the patient can move from Phase 1 recovery to Phase 2 recovery. It measures the patient’s O2 saturation, consciousness, circulation respirations, and activity.
Total score is 10.
>8 can move to Phase 2.
ASA Score
The ASA physical classification system is used to determine how healthy a patient is before surgery.
ASA 1 = healthy patient
ASA 2 = uncomplicated pregnancy, mild systemic disease, such as obesity or controlled diabetes.
ASA 3 = patient has 1+ severe systemic illnesses such as preeclampsia with severe features, gestational DM with complications, CAD, angina, or poorly controlled HTN
ASA 4 = life threatening illness such as pulmonary dysfunction
ASA 5 = patient is not expected to survive for more than 24hours unless surgery occurs.
ASA 6 = patient is brain-dead but may be an organ donor.
Coombs
The Coombs test checks the blood of the mother and the baby to determine whether or not they are Rh positive or negative.
If the mom is negative and the baby is positive, then administer RhoGAM, which is a vaccine that shields the mom’s blood from the antigens in the baby’s positive blood, which protects the baby.
Blood Type & Screen
Blood type and screen is a blood test that looks for the blood type of a mom and baby to determine if they are compatible.
Blood types are A, B, AB, or O
And all of these can have a combination of Rh+ or RH-.
AB+ is considered the universal recipient.
O- is considered the universal donor.
If the mother has Rh- and the baby has Rh+, then the mother’s blood will recognize the baby’s blood as foreign and develop antibodies that could attack the baby’s red blood cells.
Babies in this situation might need treatment for anemia or jaundice or other complications.
The mom might need the Rhogam vaccine during pregnancy.
Edinburgh Postpartum Depression Score (EPDS)
The EPDS is a 10-question screening tool that asks about the past 7 days and is used to determine whether or not a new mom might benefit from behavioral health follow up care.
13+ the new mom needs a follow up screening within 2-4 weeks. If the 2nd EPDS is 13+, then refer that mom to an appropriate health professional.
If Q10 has scores of 1, 2, or 3, then the woman and her baby (ies) safety would need to be assessed.
If Q3, Q4, or Q5 suggest symptoms of anxiety, a follow up visit or referral may also be appropriate.
Pain & PQRST
Pain is subjective, so we need some way to quantify it. Pain scores on a scale of 0-10 are a good way to communicate a person’s pain.
PQRST is a pneumonic for assessing pain.
P = provocation/ palliation
Q = quality / quantity
R = Region / Radiation
S = Severity Scale
T = timing
0-3 is mild pain
4-7 is moderate pain
8-10 is severe pain
PT / INR
PT = Prothrombin Time. It measures how long it takes for a clot to form in a blood sample. Prothrombin is a clotting factor that turns into thrombin with the assistance of clotting factor V.
Normal PT level is approximately 11-16 seconds.
INR = International Normalized Ratio. It’s calculated from the PT level and is used to monitor patients who are taking Warfarin.
Normal INR is <1.1, and between 2-3 if the patient is on warfarin.
The nurse should educate the patient about how to protect themselves from an injury such as using soft-bristled toothbrush and nonabrasive toothpaste, avoiding rectal suppositories or thermometers, limit straining with bowel movements or forceful nose blowing, be careful when using sharp objects like scissors and knives.
Platelets
Platelets are formed from bone marrow. When an injury occurs at a site, collagen releases activators and thrombocytes bind together. Platelets travel to the site, along with other clotting factors, adhere to the site, and increase stimulation for PLT until a clot is formed with fibrin.
100,000 – 450,000 / mcL
Elevated platelets can mean cancers, birth control, polycythemia vera
Decreased platelets (thrombocytopenia) could mean an autoimmune disease, meds, hemorrhage, leukemia
Rubella Screen
Rubella is a disease that can be very dangerous for a woman and her baby. The earlier the baby contracts rubella, the worse it is for the baby. Particularly in the first 12 weeks.
A rubella test detects antibodies that are made by the immune system to help kill the rubella virus.
7 IU/mL or less is negative.
8-9 IU/mL is equivocal, need to repeat testing in 10-14 days.
10 IU/mL or more is positive and indicates a current or previous exposure/immunization to rubella.
Common birth defects from congenital rubella syndrome (CRS) include deafness, cataracts, heart defects, intellectual disabilities, liver and spleen damage, LBW, and skin rash.
If the mother is infected within the 1st 20 weeks of pregnancy, she is likely to have miscarriage, stillbirth, or a baby with CRS.
LATCH score
LATCH is a measurement of how well the baby is attaching to the nipple and feeding.
L = latch,
A = audible swallowing,
T = type of nipple,
C = comfort,
H = hold
LATCH assessment is out of 10 points. 0-3 is poor; 4-7 is moderate, and 8-10 is good.
